MHK CareProminenceTM

Integrated medical and pharmacy management

The only platform that combines pharmacy and medical care, MHK CareProminence was purposely built to improve member care by closing care gaps while ensuring continual compliance with changing government regulations.

A Time For Introspection: Health Plans Have A Lot To Think Through During COVID Crisis

A Time For Introspection: Health Plans Have A Lot To Think Through During COVID Crisis

While the COVID-19 crisis has led many health-plan executives to work 12-hour days ad nauseam to react to short-term demands and put out fires, it has also triggered some introspection. Health-plan executives are soul-searching and asking themselves, “Are we doing things right, and what can we do to adapt?”

First, the fires. Health plans have had to find ways to go fully virtual. While many had begun downsizing offices in favor of work from home, there was still a lot to do in a very short time. That meant infrastructure changes to allow employees to connect to plan systems from home in a secure, quick, and efficient manner. Plans have been battling vendors who were not prepared for the move to a virtual world. Insurers have implemented utilization management changes to react to the COVID crisis, both lifting authorizations generally and reacting to specific COVID virus demands. While prior authorization and appeal demands are less right now, case and disease management interventions have increased due to the national lockdown, isolation, and closure of many providers. Plans are also preparing for the expected surge of elective surgery and other requests that will come if the virus subsides in a few weeks or months.

Now, the introspection. The evidence was clear for years that the American health-care system was on the wrong course. We spend more money than any other developed country — in terms of percentage of gross domestic product (GDP) and when looking at per-capita costs based on purchasing power parity (PPP). Nonetheless, while we have the greatest, technologically driven, on-demand health-care system in the world, our overall health outcomes are at the bottom of developed nations.

The Centers for Medicare and Medicaid Services (CMS) and some trail-blazing employers quietly began efforts years ago to shift us from a utilization management/prior authorization (UM/PA) driven system to a care management and prevention one. Health plans have adopted some of these changes but still were slow to truly endorse them. The UM/PA system chugged on. It chopped a small percentage of dollars out of the system, but overall costs have largely continued to rise considerably, outpacing GDP and income growth demonstrably. The lack of focus on care management, wellness and prevention has huge costs to the system, costs that UM/PA will never make up for. Statistics show hospitalizations for simple-to-control chronic conditions are off the charts.

Will COVID change all this? From what I hear – perhaps. COVID seems to show the inadequacy of current approaches. Short of stopping investments in change, plans seem to be embracing it right now and for all the right reasons. UM/PA will forever remain a part of what health plans do. Health plans, however, are looking to make this process easy and efficient through the following:

Abandoning old technologies (are there really fax machines still out there?) and pursuing digital strategies to receive case requests and update members and providers of decisions.

Auto approving such requests, with the support of technology systems with evidence-based criteria, whenever possible to further drive down administrative costs.

Beginning to seed the future for coupling authorizations and claim payments in real-time.

More important, health plans seem to be preparing for major investments in population health and care management approaches that leverage technology to engage members and providers. Some areas emerging include:

Yes, it will take some time, but COVID seems to be pointing plans toward thinking about the advantages of focusing on overall member health rather than individual health-care transactions. It also focuses a positive light on how technology (through remote engagement, telehealth, etc.) can be used to great success in health care.

For all the despair it has caused, COVID may fundamentally change thinking for the good in health care.

Marc S. Ryan serves as MHK’s President and was one of MHK’s first executives shortly after its founding in 2010. Most recently, Marc served as MHK’s Executive Vice President and Chief Operating Officer and before that as its Chief Strategy and Compliance Officer.

Prior to joining MHK, Marc held a number of executive-level regulatory, compliance, business development, and operations roles at a number of health plans. He launched and operated plans with Medicare, Medicaid, commercial and Exchange lines of business.

He also was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program.

Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He was also nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was also inducted into Sigma Beta Delta, a national honor society for business, management and administration.

MHK, part of the Hearst Health network, is a Medical House of Knowledge, where care and knowledge converge. The only service provider that combines pharmacy and medical, MHK’s mission is to drive better member care in a changing healthcare environment by bringing every care moment in a person’s health journey together through an integrated platform. MHK is committed to helping health plans, PBMs, and provider organizations improve quality of care, enhance operational efficiency, maximize revenue, and meet compliance demands. Three of the top five and six of the top ten health plans are served by MHK and forty percent of all 4-5 Star Medicare health plans utilize MHK solutions.